Medical Benefits

Blue River Plumbing – Group #1477187

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a
medical plan that meets your needs and the needs of your family. Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.myuhc.com.

In-Network Benefits	$500 Buy-Up Plus Plan	$3,000 Buy-Up Plan	$5,000 HSA Plan
Deductible (Individual/Family)	$500 / $1,000	$3,000 / $6,000	$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)	$4,000 / $8,000	$5,500 / $11,000	$7,000 / $14,000
Member Coinsurance (Plan pays/You pay)	80% / 20%	100% / 0%	80% / 20%
Physician Visits
Primary Care	$25 Copay (under age19 $0 Copay)	$25 Copay (under age19 $0 Copay)	Deductible, then $25 Copay
Routine Preventive	No Cost	No Cost	No Cost
Specialist	$75 Copay	$75 Copay	Deductible, then $75 Copay
Hospital Services
Physician Services	Deductible, then 20%	Deductible	Deductible, then 20%
Inpatient Hospitalization	Deductible, then 20%	Deductible	Deductible, then 20%
Outpatient Surgery	Deductible, then 20%	Deductible	Deductible, then 20%
Basic Outpatient Diagnostics	Deductible, then 20%	Deductible	Deductible, then 20%
Urgent Care	$50 Copay	$50 Copay	Deductible, then $50 Copay
Emergency Room	$300 Copay; Deductible, then 20%	$300 Copay; Deductible	$300 Copay; Deductible, then 20%
Prescription Drugs
Retail Prescriptions
Tier 1	$10	$10	Deductible, then $10
Tier 2	$35	$35	Deductible, then $35
Tier 3	$75	$75	Deductible, then $75
Tier 4	$250	$250	Deductible, then $250
Mail Order Prescriptions
Tier 1	$25	$25	Deductible, then $25
Tier 2	$87.50	$87.50	Deductible, then $87.50
Tier 3	$187.50	$187.50	Deductible, then $187.50
Tier 4	$625	$625	Deductible, then $625
Note: Specialty Rx may have different copays

	$500 Buy-Up Plus Plan Weekly Cost	$3,000 Buy-Up Plan Weekly Cost	$5,000 HSA Plan Weekly Cost
Employee Only	$41.77	$21.16	$0.00
Employee + Spouse	$87.83	$44.51	$0.00
Employee + Child(ren)	$81.55	$41.32	$0.00
Employee + Family	$127.62	$64.68	$0.00

Downloads

Summary of Benefits - $500 Buy-Up Plan

Summary of Benefits - $3,000 Buy-Up Plan

Summary of Benefits - $5,000 HSA Plan

UHC Digital Engagement Flyer

Great Plains Plumbing – Group #1621405

In-Network Benefits	$500 Buy-Up Plus Plan	$3,000 Buy-Up Plan	$5,000 HSA Plan
Deductible (Individual/Family)	$500 / $1,000	$3,000 / $6,000	$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)	$4,000 / $8,000	$5,500 / $11,000	$7,000 / $14,000
Member Coinsurance (Plan pays/You pay)	80% / 20%	100% / 0%	80% / 20%
Physician Visits
Primary Care	$25 Copay	$25 Copay	Deductible, then $25 Copay
Routine Preventive	No Cost	No Cost	No Cost
Specialist	$75 Copay	$75 Copay	Deductible, then $75 Copay
Hospital Services
Physician Services	Deductible, then 20%	Deductible	Deductible, then 20%
Inpatient Hospitalization	Deductible, then 20%	Deductible	Deductible, then 20%
Outpatient Surgery	Deductible, then 20%	Deductible	Deductible, then 20%
Basic Outpatient Diagnostics	Deductible, then 20%	Deductible	Deductible, then 20%
Urgent Care	$50 Copay	$50 Copay	Deductible, then $50 Copay
Emergency Room	$300 Copay; Deductible, then 20%	$300 Copay; Deductible	$300 Copay; Deductible, then 20%
Prescription Drugs
Retail Prescriptions
Tier 1	$10	$10	Deductible, then $10
Tier 2	$35	$35	Deductible, then $35
Tier 3	$75	$75	Deductible, then $70
Tier 4	$250	$250	Deductible, then $150
Mail Order Prescriptions
Tier 1	$25	$25	Deductible, then $25
Tier 2	$87.50	$87.50	Deductible, then $87.50
Tier 3	$187.50	$187.50	Deductible, then $187.50
Tier 4	$625	$625	Deductible, then $375
Note: Specialty Rx may have different copays

	$500 Buy-Up Plus Plan Weekly Cost	$3,000 Buy-Up Plan Weekly Cost	$5,000 HSA Plan Weekly Cost
Employee Only	$68.27	$54.59	$30.41
Employee + Spouse	$138.97	$110.26	$59.48
Employee + Child(ren)	$121.46	$94.80	$47.64
Employee + Family	$192.17	$150.46	$76.71

Downloads

Summary of Benefits - $500 Buy-Up Plan

Summary of Benefits - $3,000 Buy-Up Plan

Summary of Benefits - $5,000 HSA Plan

UHC Digital Engagement Flyer

Progressive Safety – Group #1726226

In-Network Benefits	$500 Buy-Up Plus Plan	$3,000 Buy-Up Plan	$5,000 HSA Plan
Deductible (Individual/Family)	$500 / $1,000	$3,000 / $6,000	$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)	$4,000 / $8,000	$5,500 / $11,000	$7,000 / $14,000
Member Coinsurance (Plan pays/You pay)	80% / 20%	100% / 0%	80% / 20%
Physician Visits
Primary Care	$25 Copay	$25 Copay	Deductible, then $25 Copay
Routine Preventive	No Cost	No Cost	No Cost
Specialist	$75 Copay	$75 Copay	Deductible, then $75 Copay
Hospital Services
Physician Services	Deductible, then 20%	Deductible	Deductible, then 20%
Inpatient Hospitalization	Deductible, then 20%	Deductible	Deductible, then 20%
Outpatient Surgery	Deductible, then 20%	Deductible	Deductible, then 20%
Basic Outpatient Diagnostics	Deductible, then 20%	Deductible	Deductible, then 20%
Urgent Care	$50 Copay	$50 Copay	Deductible, then $50 Copay
Emergency Room	$300 Copay; Deductible, then 20%	$300 Copay; Deductible	$300 Copay; Deductible, then 20%
Prescription Drug
Retail Prescriptions
Tier 1	$10	$10	Deductible, then $10
Tier 2	$35	$35	Deductible, then $35
Tier 3	$75	$75	Deductible, then $75
Tier 4	$250	$250	Deductible, then $250
Mail Order Prescriptions
Tier 1	$25	$25	Deductible, then $25
Tier 2	$87.50	$87.50	Deductible, then $87.50
Tier 3	$187.50	$187.50	Deductible, then $187.50
Tier 4	$625	$625	Deductible, then $625
Note: Specialty Rx may have different copays